Medical examiner Stéphanie Gamache’s report, released on Tuesday, describes the lack of training and communication between the various health care providers involved in the Pomares case. In addition, the lack of guidelines and resources trained to deal with suicide attempts in a collapse context prevented a more appropriate intervention in this case, he wrote. The medical examiner’s recommendations include asking the Ministry of Health and Social Services to set up an evaluation grid for such cases and to train all health workers and professionals on an ongoing basis at the CIUSSS du Center-Sud-de-l’Île -de- Montréal and de l’Est-de-l’Île-de-Montréal, who were involved in this case. It also provides training on when to remove the confidentiality rules that prevented the transmission of information to professionals about the real risk posed by Pomares. Finally, he called on the Secrétariat à la condition féminine to extend the creation of crisis cells specializing in such interventions, which already exist in other areas, to the two CIUSSS stakeholders. Pomares’s ex-wife had told him he wanted to end their relationship on October 12. The next day, Pomares, who had previously stopped drinking excessively, consumed a large amount of alcohol in combination with several ibuprofen tablets. Upon learning of this, his ex-wife contacted 911. He strongly resisted being taken to hospital and had denied any suicide attempts, Gamache wrote. But the psychiatrist who saw him at Notre-Dame Hospital ruled that he was in a serious collapse and that he was in high risk for himself and unpredictable for others. On October 14, due to his place of residence, he was transferred from Notre-Dame to the IUSMM psychiatric hospital where, once again, the psychiatrist who evaluated him considered it necessary to place him in protective custody.
LACK OF INFORMATION
However, on October 15, a second psychiatrist at the institute decided to dismiss him based solely on his discussions with Pomares. Pomares was allowed to go live with a friend and consult a psychosocial worker. Gamache felt that this psychiatrist did not have a complete picture of his condition as he could not communicate with his ex-wife, he wrote. Although she was surprised that she was unknowingly discharged, Pomares’s ex-wife agreed that she could stay with the children, Hugo and iselise, aged seven and five, respectively. On October 22, the day of the tragedy, Pomares went to pick up the children at the end of their school day as agreed, and had to prepare dinner for them waiting for their mother to arrive, around 9:30 p.m. When she arrived, she found the bodies of her children and her ex-husband, who had been hanged. This report by The Canadian Press was first published in French on April 12, 2022.
